Healthcare Provider Details

I. General information

NPI: 1508199605
Provider Name (Legal Business Name): JAN OKABE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. JAN OKABE-WONG

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 09/22/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

IV. Provider business mailing address

323 N PRAIRIE AVE
INGLEWOOD CA
90301-4502
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-6612
  • Fax: 310-398-5690
Mailing address:
  • Phone: 310-677-7808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY27666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: